We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Hello, my name is Denis Ougrin. I'm a professor of child psychiatry based at Queen Mary University of London. I'm going to talk to you today about TRT+P, which stands for Teaching Recovery Techniques plus Parenting. TRT+P, Teaching Recovery Techniques plus Parenting was designed by a group of my colleagues in the mid to late '90s at the Institute of Psychiatry, King's College London. Some of the key people who designed it were Professor Bill Yule, who sadly passed away just a few months ago, and his colleagues. The programme was designed for children affected by the Bosnian war at the time. And since then, it has been used in a number of contexts in different countries for children and parents affected by wars, but also by natural disasters. So the main goal of TRT plus parenting is really to give young people and their parents or carers skills on how to deal with manifestations of post-traumatic stress disorder, and also how to optimise the way that parents or carers support children in the context of wars or perhaps natural disasters. TRT+ consists of five sessions for children. They are about 90 minutes each. And the way that these sessions are designed is that they are there to help children and adolescents deal with some of the key difficulties that come with PTSD. So these sessions are designed to help young people cope with flashbacks and re-experiencing in general, and intrusive memories of what happened. That's the one component. Then there is a part of the programme, which is designed to deal with hyperarousal. And that's mainly how to deal with children who respond in a very big way to small stimuli, such as jumping when there's a loud noise or hiding or being hyperaroused in general. And then finally, there is a part of the programme, which is to do with avoidance and how to overcome avoidance. That's quite a difficult part and requires a little bit more of a thinking, starting with what is good avoidance, especially if children are still in unsafe environments, and then moving on to the unhelpful avoidance and how to overcome that. Now with parents, they go through similar skills as well, and they understand what children get taught during their groups. But the +P is the three extra sessions the parents get. And that is not just to do with PTSD, but also how to provide the best possible parenting to children who might be affected by war-related trauma, but also acknowledging that parenting does change at times of disasters and wars, and how to best go about supporting children when they are at their most vulnerable. So we undertook a cluster-randomised study, which is to say that we took all schools in one particular city called Ternopil, which is based in the west of Ukraine. And we randomly allocated all of these schools to either receive training in TRT+P or receive the same training, but later on, delayed. So we finished the training part, and we trained primarily school psychologists. Now in Ukraine, most schools have at least one school psychologist. And really, most of them were really very keen to get this extra set of skills. It was a two-day training, which I did with a wonderful colleague of mine who's a psychologist from Ukraine. And to be fair to say, the training which was delivered in Ukrainian, was very well received. Now, before we did this study, we undertook a very large survey of children's PTSD symptoms-- and not the diagnosis but symptoms-- using a questionnaire called CRIES-8, which is very commonly used. And what we have found was, really, a very large and quite surprising prevalence of PTSD symptoms in children in Ternopil. Remember that it's a western city, which is not directly on the front line. And although Russians do target it once in a while with ballistic missiles and drones, it's very rare in comparison to some of the eastern cities. And nonetheless, children are affected by regular air raid sirens, and they have to go into shelters and their school gets interrupted. And what we found was that about 40% of children have significant PTSD symptoms, which is a lot more than what we anticipated. Then we took these schools and we looked at the number of children who might have benefited from this intervention, from TRT+P, and their parents. And we don't yet have outcomes for the main outcome measure, which is the change in CRIES-8 questionnaire. But we know that approximately the number of children that we anticipated, just around 250, did receive the intervention. And so we should be able to have a definitive answer to this question before the end of the year, when we analyse everything. What it looks like is that at the very least, most children liked it. And most of them would also recommend the training to their friend, which was good to see. As far as the main outcome measures, so we don't have the data yet. We haven't analysed it yet, but it's all gathered. We don't know whether the training in these groups have made a difference. And the reason for this is because no one has done a study like this in a country that which is currently still affected by a war. It may well be the case that because of this constant stress and air raids and shelters and so on that children did not benefit as much as perhaps in other settings. But it may be that they did, and I'd be delighted to report the main outcome as soon as we have it. In terms of implementation and learning, then I'd say that there are some differences that Ukrainian children have from other children they have seen. And partly, this is to do with the nature of the war. And partly, I think it is to do with the availability of a relatively large, I have to say, support network that they have in Ukraine. Perhaps in some other countries, the problem is that there isn't enough support. In Ukraine, quite often there is almost too much support. There are so many people who are offering help that some Ukrainian psychologists are a bit overwhelmed. And they say, well, we don't know whether this model is better or that model is better. And the evidence base is not very clear. They're overlapping as well. And so, really, even for the TRT training, we had to exclude a few schools, not a huge number, maybe three or four, because their school psychologists had already received training in TRT. So when you start in Ukraine, you very rarely start from scratch like in some other countries. Another thing is to do with the nature of the war because Russians rely so heavily on their long-range artillery and also ballistic missiles, then I think there is a difference in the sense that many children get very, very scared by certain types of noises and this sort of unpredictability of where the missiles are coming from. And the very short time between the air raid alert and the actual explosion is something that seems to be quite different from some other conflicts that I have seen. Also, interestingly, we do not see, in Ukrainian children, the same amount of stress when they are exposed to uniforms, to soldiers. I have seen children from other war-related circumstances who responded very badly to uniforms, but Ukrainian kids seem to be fine with that. But they do respond very differently to certain noises, like train noises and certain other noises that they hear around them, which probably have something to do with the frequency of these long-range missiles. In Ukraine, we have internally displaced people, as well as people who live in that city. And there are some differences, although not as huge as we anticipated. But obviously, people who are internally displaced are people who often moved from the east of the country to the west. Very often, they lost everything, all their property, and sometimes they lost family members. And many of them had to cross the front line. And that sort of crossing for many children is a very challenging and difficult period. So the level of trauma in young people from Ternopil and young people from the east of the country was quite different. So that was a challenge. And our school psychologists had to consider how to manage that, whether children with different levels of trauma, exposure had to be in the same group or in different groups. So first of all, we need to find out what the outcome of the study was. If it looks like there was a difference and children who received TRT+P, plus parenting, did better than children who did not, then I think there'd be a fair case for implementing this procedure broadly in Ukraine. It has already been recommended by the ministry of education of Ukraine, just TRT without parenting, as one of the options. But with that level of evidence, it should become the main option. The main thing that school psychologists and perhaps other people are trained in. If it doesn't work, then we would need to consider what other interventions are more appropriate. For instance, we're just about to publish a study with my colleagues from Harvard looking at training all the teenagers in Ukrainian schools in problem-solving skills digitally, remotely. There are also indications that, just for example, training young people in relaxation techniques doesn't seem to work. Again, we've just published a study showing that. So I think the direction of travel will depend on the outcome of course. But somewhat irrespective of the outcome, we might want to consider digital interventions. That's something that is important not just for Ukraine, but also for other future conflicts as well, and especially for places where there is much less help, such as in Gaza, for example. I'd say that reaching out to children in these very difficult circumstances, it feels important. We don't know whether we can make a difference yet or not because we have not got any studies in the country with active warfare. This will be the first one. But it'd be good to understand, one, what are the key ingredients of these programmes that seem to make a difference? And two, what is the best way to deliver? We will never be able to deliver the right intervention to all kids who need it, but digital interventions in the digital pathway offer some hope. That's all. Thank you.